By Counterforce Health Team in Cerezyme (imiglucerase) —

How to Get Cerezyme (Imiglucerase) Covered by Aetna CVS Health in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cerezyme Covered by Aetna CVS Health in Texas

Aetna CVS Health requires prior authorization for Cerezyme (imiglucerase) with Elelyso as preferred step therapy. Texas law provides strong appeal protections with 180-day filing deadlines and binding external review through Independent Review Organizations (IROs).

Fastest path to approval:

  1. Document confirmed Gaucher disease diagnosis (enzyme assay/genetic testing)
  2. Prove Elelyso trial failure, intolerance, or contraindication
  3. Submit PA via Aetna provider portal or fax 1-888-267-3277

Start today: Contact your hematologist to gather diagnostic labs and prior therapy records. Texas residents have unique step therapy override rights under Insurance Code Section 1369.0546.

Table of Contents

Why Texas State Rules Matter

Texas Insurance Code provides robust patient protections that interact with Aetna CVS Health's national policies. Unlike many states, Texas mandates specific timelines for prior authorization decisions and creates binding external review processes through the Texas Department of Insurance (TDI).

For Cerezyme patients, this means:

  • 72-hour response requirement for standard PA requests (24 hours for urgent cases)
  • Automatic approval if Aetna fails to respond within these timeframes
  • Step therapy override rights with specific medical exception criteria
  • Binding external review at no cost to patients through Independent Review Organizations

These protections apply to state-regulated plans but not ERISA self-funded employer plans, which follow federal rules only.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Cerezyme prescriptions Aetna provider portal Aetna PA List 2026
Step Therapy Must try Elelyso first unless contraindicated CVS Caremark formulary PrescriberPoint Forms
Diagnosis Requirement Confirmed Gaucher disease via enzyme/genetic testing Medical records Aetna Clinical Policy
Specialist Involvement Hematologist or Gaucher expert required Referral documentation Aetna Medicare Part B Form
Appeal Deadline 180 days from denial notice Texas Insurance Code TDI Consumer Guide
External Review Available after internal appeal denial TDI IRO process TDI IRO Information

Step-by-Step: Fastest Path to Approval

1. Confirm Gaucher Disease Diagnosis (Patient + Clinic)

What you need: β-glucocerebrosidase enzyme assay results or genetic testing showing GBA mutations Timeline: Immediate if already tested; 1-2 weeks for new testing Submit via: Include in medical records for PA submission

2. Document Step Therapy Attempts (Clinic)

What you need: Records of Elelyso trial showing inadequate response, intolerance, or medical contraindication Timeline: Must be recent (typically within 12 months) Submit via: Prior authorization form with detailed failure documentation

3. Engage Hematologist or Gaucher Specialist (Patient)

What you need: Specialist evaluation and treatment recommendation Timeline: 2-4 weeks for new consultation Submit via: Specialist letter of medical necessity

4. Submit Prior Authorization (Clinic)

What you need: Aetna PA form, medical records, specialist letter Timeline: Aetna must respond within 72 hours (standard) or 24 hours (urgent) Submit via: Provider portal or fax 1-888-267-3277

5. Track PA Status (Patient + Clinic)

What you need: Reference number from submission Timeline: Check status after 48 hours Submit via: Call 1-866-752-7021 or check provider portal

6. Handle Denials Immediately (Patient + Clinic)

What you need: Written denial notice with specific reasons Timeline: File appeal within 180 days of denial Submit via: Internal appeal process first, then Texas IRO if needed

7. Implement Continuity Protections (Patient)

What you need: Documentation of ongoing therapy needs Timeline: Request during appeal process Submit via: Continuation of care request with medical urgency documentation

Texas Step Therapy Protections

Under Texas Insurance Code Section 1369.0546, Aetna CVS Health must grant step therapy overrides when providers document that the required drug (Elelyso):

Override Criteria:

  • Is contraindicated or will cause adverse reactions
  • Is expected to be ineffective based on patient characteristics
  • Patient previously discontinued due to ineffectiveness or adverse events
  • Is not in the patient's best interest (creates barriers to adherence, worsens comorbid conditions)
  • Patient is stable on current drug (Cerezyme) and changing would cause harm

Response Timeline:

  • 72 hours for standard requests (automatic approval if no response)
  • 24 hours for urgent cases where delay could cause serious harm
From our advocates: We've seen Texas patients successfully override step therapy requirements by having their hematologist document specific enzyme levels and bone marrow findings that make Elelyso inappropriate. The key is connecting clinical data to the statutory override criteria in your appeal letter.

Appeals Playbook for Texas

Internal Appeal Process

Deadline: 180 days from denial notice Submit to: Aetna member services or provider portal Timeline: 30 days for standard decisions, 72 hours for urgent Required: Denial letter, medical records, specialist support

External Review (IRO)

When available: After internal appeal denial for medical necessity disputes Deadline: 120 days from internal denial Submit to: Texas Department of Insurance IRO Cost: Free to patient Timeline: 30 days standard, 72 hours urgent Decision: Binding on Aetna

Urgent/Expedited Appeals

Qualify for expedited review when delay would:

  • Risk serious adverse health consequences
  • Cause severe pain
  • Impair ability to perform daily activities
  • Jeopardize patient's ability to regain maximum function

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Cite Texas override criteria Medical contraindication to Elelyso, prior failure records
"Not medically necessary" Provide FDA approval evidence FDA label, peer-reviewed studies, specialist letter
"Experimental/investigational" Document FDA approval for Gaucher FDA approval letter, established clinical guidelines
"Quantity limits exceeded" Show medical need for specific dosing Weight-based calculations, treatment response data
"Non-formulary drug" Request formulary exception Comparative effectiveness data vs. formulary alternatives

At Counterforce Health, we help patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific policies and Texas state requirements.

Continuity of Care Protections

Texas provides several continuity protections for ongoing Cerezyme therapy:

Coverage Transitions

  • Plan changes: Aetna must provide transition coverage for ongoing specialty medications
  • Provider network changes: Continued access during network disruptions
  • Prior authorization renewals: Annual limits prevent repeated step therapy requirements for stable patients

Medicaid Protections

Under 1 Tex. Admin. Code § 353.7, children age 20 or younger with complex medical needs can continue with out-of-network specialists through single-case agreements.

Emergency Supply Rules

Pharmacists can provide 3-day emergency supplies for specialty medications during prior authorization delays, with full dosing maintained for clinical appropriateness.

Consumer Assistance Programs

State Resources

  • Texas Health Options: 1-800-252-3439 for general insurance assistance
  • Texas Department of Insurance: Consumer complaint portal
  • Office of Public Insurance Counsel (OPIC): 1-877-674-2839 for appeals guidance

Advocacy Organizations

  • Disability Rights Texas: 1-800-252-9108 for free legal advocacy on insurance denials
  • National Gaucher Foundation: Disease-specific support and resources
  • Patient Advocate Foundation: Copay assistance and insurance navigation

Financial Assistance

  • Sanofi Patient Connection: Manufacturer assistance program
  • Chronic Disease Fund: Copay assistance for eligible patients
  • HealthWell Foundation: Disease-specific financial support

For comprehensive support navigating prior authorization and appeals processes, Counterforce Health provides specialized assistance in turning insurance denials into successful appeals through evidence-based advocacy.

FAQ

How long does Aetna CVS Health prior authorization take in Texas? Standard PA decisions must be made within 72 hours under Texas law. Urgent cases require 24-hour response. Automatic approval occurs if Aetna fails to respond within these timeframes.

What if Cerezyme is non-formulary on my plan? Request a formulary exception alongside your PA. Document medical necessity and why formulary alternatives (Elelyso, VPRIV) are inappropriate through specialist evaluation and clinical evidence.

Can I request an expedited appeal in Texas? Yes, if delay would risk serious health consequences. Mark your appeal "urgent" and have your physician certify that delay could cause harm. Texas requires 72-hour decisions for expedited external reviews.

Does step therapy apply if I've been stable on Cerezyme? No, Texas law protects stable patients. If you're currently stable on Cerezyme, switching to Elelyso could cause harm, qualifying for step therapy override under Insurance Code Section 1369.0546.

What documents do I need for a successful appeal? Essential documents include: denial letter, complete medical records, Gaucher disease confirmation (enzyme/genetic tests), prior therapy failure documentation, specialist letter of medical necessity, and FDA approval evidence.

How much does external review cost in Texas? External review through Texas IRO is completely free to patients. The state contracts with Independent Review Organizations and insurers pay all costs.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and appeals processes. It is not medical advice. Always consult your healthcare provider about treatment decisions and work with your clinical team on prior authorization and appeals. Insurance policies and state regulations may change; verify current requirements with official sources.

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